9 Prevention, Assessment, and Treatment of Psychological Effects

Incidents of chemical and biological terrorism may involve large numbers of individuals, across all age groups and in both sexes. The survivors of and responders to such incidents will not only suffer physical injury requiring decontamination and medical care but also will undoubtedly undergo extreme psychological trauma. Thus, chemical or biological weapons of mass destruction could produce both acute and chronic psychiatric problems. Unlike storms or floods, chemical disasters occur with little or no warning and are accompanied by continuing fears of ongoing illness and premature death (Bowler et al., 1997) as well as worries about possible genetic or congenital birth defects in subsequent offspring. In the case of terrorism, particularly when the aggressor is unknown, a potentially beneficial expression of anger cannot be directed at the appropriate source, producing a futile sense of helplessness, depression, demoralization, and hopelessness.

Long-Term Effects of Terrorism (Post Traumatic Stress Disorder)

The literature on civilian terrorist attacks reveals a number of reports of very high rates of Post Traumatic Stress Disorder (PTSD) after such attacks. In a study in France, Abenhaim, Dab, and Salmi (1992) followed 254 survivors of terrorist attacks over a period of five years. These authors report that even years after the attacks, the severely injured had a 30.7 percent prevalence of PTSD, and uninjured victims had a 10.5 percent

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Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response.
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9 Prevention, Assessment, and Treatment of Psychological Effects Incidents of chemical and biological terrorism may involve large numbers of individuals, across all age groups and in both sexes. The survivors of and responders to such incidents will not only suffer physical injury requiring decontamination and medical care but also will undoubtedly undergo extreme psychological trauma. Thus, chemical or biological weapons of mass destruction could produce both acute and chronic psychiatric problems. Unlike storms or floods, chemical disasters occur with little or no warning and are accompanied by continuing fears of ongoing illness and premature death (Bowler et al., 1997) as well as worries about possible genetic or congenital birth defects in subsequent offspring. In the case of terrorism, particularly when the aggressor is unknown, a potentially beneficial expression of anger cannot be directed at the appropriate source, producing a futile sense of helplessness, depression, demoralization, and hopelessness.
Long-Term Effects of Terrorism (Post Traumatic Stress Disorder) The literature on civilian terrorist attacks reveals a number of reports of very high rates of Post Traumatic Stress Disorder (PTSD) after such attacks. In a study in France, Abenhaim, Dab, and Salmi (1992) followed 254 survivors of terrorist attacks over a period of five years. These authors report that even years after the attacks, the severely injured had a 30.7 percent prevalence of PTSD, and uninjured victims had a 10.5 percent

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rate. In two other studies of terrorist attacks (Curran et al., 1990; Weisaeth, 1989) PTSD rates higher than 40 percent are reported.
In addition to PTSD, many of the victims of a terrorist attack may suffer the death of family members, close friends, or work colleagues, which can lead to a complicated bereavement with its own elevated risk for depression, self medication, and substance abuse. Many studies indicate that depression is a common co-morbid condition with PTSD. Somatic sequelae to anxiety-related reactions have been reported in most studies of PTSD as well as following the Persian Gulf war. Carmeli, Liberman, and Mevorach (1994) reported that American veterans had a 38 percent prevalence rate of somatic symptoms, and Deahl et al. (1994) report a 50 percent prevalence of some ''psychological disturbance suggestive of PTSD" in British soldiers who handled and identified dead bodies of allied and enemy soldiers during the recent Gulf War. These reports suggest that chemical and biological terrorist attacks might cause high rates of PTSD and risks for physical illnesses and suicide, not only among rescue workers but especially among unprepared witnesses to grotesque sights and untrained "good samaritans" voluntarily joining rescue and first aid efforts.
The early identification of persons at risk for long-term psychological effects is complicated by the fact that PTSD symptoms within a few days of a traumatic event have been shown to have low predictive validity by themselves for later psychiatric outcome (Shalev, 1992). Recording of signs and symptoms in the immediate aftermath of the traumatic event should certainly be supplemented by systematic recording of objective and subjective features of the terrorist attack and its aftermath by all who were at the scene. The latter sort of information has often been critical to post hoc "prediction" of long-term dysfunction. PTSD is difficult to treat, and even when treated shortly after onset, as was the case with the Japanese sarin victims, 30 percent of the patients required ongoing therapeutic treatment (Nakano, 1995). In addition to the need for rapid identification of those who may require immediate or long-term psychiatric treatment, neuropsychological testing is important to evaluating effects on cognition, memory, and personality as well as any possible organic sequelae from the chemical agents used in terrorist attack.
Short-Term Effects of Terrorism (Acute Needs) At the acute stage of the aftermath of a biological or chemical terrorist attack, acute autonomic arousal and panic may result in both the victims and the emergency responders (Hazmat teams, police, fire, medical) incapacitating the assistance infrastructure. The severity of these anticipated

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psychological responses highlights the urgent need for concrete mental health support at times of chemical or biological terrorist attacks.
At the regional and national levels, the American Red Cross Disaster Mental Health Services provides emergency and preventive mental health services to both people affected by the disaster and to Red Cross workers assigned to the disaster relief operation. These services include practical measures like meeting families traveling to the scene, communicating with families not at the scene, offering education about stress and coping, and providing information about local mental health resources. It should be noted in this context that, as victims of a crime, many survivors of a terrorist attack are eligible for compensation and assistance through state victim assistance programs, and, as terrorist attacks are often directed at government buildings, Workman's Compensation. Coordinating access to such sources of financial assistance can be important mental health support. Victims of terrorist attacks are often witnesses in criminal proceedings as well, a role that can change the course of recovery, and may need continuing help in meeting this societal obligation.
The federal government's National Disaster Medical System (NDMS) includes Disaster Medical Assistance Teams with a focus on mental health. Another federal program is the Crisis Counseling Assistance and Training Program (CCP). Funded by the Federal Emergency Management Agency (FEMA) and administered by the Center for Mental Health Services (CMHS) in the Substance Abuse and Mental Health Services Administration, CCP provides supplemental funding to states for short-term crisis counseling services to victims of major disasters. These services are designed to help disaster survivors recognize typical reactions and emotions that occur following a disaster and to regain control over themselves and their environment. Although the focus is on short-term interventions, helping people with normal reactions to abnormal experiences rather than long-term therapy for pathological conditions, the program provides for up to 12 months of services, and local mental health workers and other disaster workers are eligible for training (training is also offered annually to state mental health authorities by FEMA's Emergency Management Institute). Thousands of people were helped by the CCP after the Northridge, California earthquake in 1993, the Oklahoma City bombing in 1995, and the floods in the Dakotas and Minnesota in 1997. CMHS also provides training and field support for a cadre of FEMA employees who provide stress management services to disaster workers.
First Responders Another important aspect of terrorism is the emotional and psychological impact on first responders. Prevention methods should be developed

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to assist first responders in terrorist attacks, whose emotional vulnerability to the traumatic events they face is already recognized in current training programs. Although the U.S. Anti-Terrorism and Effective Death Penalty Act of 1996 recommended a two-day training provided by the DoD Domestic Preparedness Program in 120 targeted urban areasand, in fact, some 6,500 fire and emergency personnel have been trained within its first yearscant emphasis is paid to the mental health needs of first responders. The current training programs include primarily technical information on the nature and effects of weapons of mass destruction. The focus is on the handling of victims with little attention to the first responders' own mental health and coping needs and strategies. An epidemiologic study conducted by the University of Oklahoma found that 20 percent of the rescue personnel at the Oklahoma City bombing required mental health treatment (Flynn, 1996). This prevalence of mental health problems in first responders demonstrates the need for qualified mental health professionals who can identify and treat vulnerable first responders and so diminish the high rate of mental disorders following terrorist attacks.
Not only is there a need to more effectively identify the mental health needs of first responders, but there is also a need for further research on various treatment methods. For example, Critical Incident Stress Debriefing (CISD), a technique aimed at helping field rescue personnel cope with the stress of extraordinary traumatic events, has gained widespread popularity (Mitchell and Everly, 1996). CISD was originally devised as a relatively rapid technique designed to alleviate stress symptoms and prevent burnout of rescue workers. It involves organized group meetings for all personnel in the rescue unit, with or without symptoms, emphasizes peer support, and is led by a combination of unit members and mental health professionals. CISD in some form has gained wide acceptance among field emergency workers and is increasingly used with hospital-based emergency personnel, military service members, public safety personnel, volunteers, victims, witnesses, and even schoolmates of victims. It can reasonably be expected that many local police, fire, and emergency medical units will be familiar with the CISD process, have access to trained debriefers, and plans for their use. The Metropolitan Medical Strike Teams being organized by the Public Health Service include CISD as part of their standard operating procedures. Objective evidence of CISD effectiveness is, nevertheless, limited and contentious (see for example Raphael et al., 1995; Kenardy et al., 1996; Hamling, 1997), and protocols typically do not allow collecting the type of screening data necessary for estimating psychiatric risk and planning extended services.

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Neurological Vs. Psychological Responses Although most, if not all, hospitals will have behavioral health staff (psychiatrists, psychologists, psychiatric nurses, counselors, and social workers) present or on call, their experience with PTSD, large-scale disasters, and terrorist acts is likely to be highly variable, and accurate information on chemical or biological agents will be very rare, at least initially. Such information will nevertheless be critical for differentiating those suffering psychological effects from those with neurological damage (Vyner, 1988).
Shapira et al. (1994) suggest an outline of a hospital organization that includes mental health professionals for a chemical warfare attack. Because many of the neurological effects of chemical agents may be confused with the emotional and psychological effects, the authors caution against assuming that the symptoms of chemical trauma victims are psychological in nature and recommend treating victims in a site other than the department of psychiatry.
In nerve gas attacks where the enzyme acetylcholinesterase is inhibited, signs of central and peripheral nervous system poisoning include apathy, mood liability, thought disorders, sleep disorders, and delusions and hallucinations, in addition to psychological stress sequelae. Mental health staff will need to rapidly identify and differentiate the diagnostic characteristics in order to refer and treat these victims as well as rescue workers, who may also suffer from emotional exhaustion and overload.
Important data on this problem of differentiating neurological and psychological effects may emerge from a follow-up study of the 1995 release of sarin in the Tokyo subway (Nakano, 1995). A small number (N = 34) of the firefighters who responded are still being followed and are being compared to 36 age- and sex-matched controls recruited from the Tokyo Metropolitan Fire Department. This long-term follow-up study is gathering information on physical and psychiatric sequelae to a nerve gas attack and includes neurological and neuropsychiatric assessments, EKG, peripheral nerve conduction, auditory-evoked potentials, serum cholinesterase levels, and ophthalmic evaluation. Although this follow-up study is of a relatively small number of victims, the information obtained may be useful in planning specific programs for those who may suffer psychological or neurological effects in future terrorist attacks.
Treatment Methods Because most of the existing studies of PTSD following chemical incidents are predominantly epidemiological in nature, the focus of research has been on sequelae rather than treatment methods and their efficacy.

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Treatment is now a very active area of clinical research, with positive treatment outcomes even among torture victims and prospects for improved intervention strategies. However, there is a need to research individual patients' responses to current treatment methods to ensure that favorable outcomes are possible for everyone. Psychological treatment of trauma victims is always complicated by an ongoing need for medical treatment and physical rehabilitation, and in the case of terrorist attacks on civilians, it is further complicated by the fact that attacks frequently occur in everyday settings to which the victims are likely to return. A public approach to treatment should thus include education about the role of reminders and environmental changes that minimize unnecessary and avoidable secondary trauma.
Populations at special risk, such as families with young children, the frail elderly and disabled, may require additional services. Recent research has suggested that the potentially profound trauma reactions in victims should not be treated by publicly venting these fears, as is encouraged in Critical Incident Stress Debriefing (CISD), but instead should receive basic medical and social services, including therapeutic validation of their fears and reassurance that they are reacting normally to an abnormal event (Bisson and Deahl, 1994). That should serve to restore some basic level of daily functioning and to help to restore the needed belief and trust in government institutions.
Training Current hospital and professional response capabilities should be reviewed for current knowledge about chemical and biological warfare agents so that these personnel will be better prepared to address the emotional sequelae likely to follow an attack with such agents. While there is some knowledge about the psychological effects of terrorism (the Oklahoma City disaster, for example) and of unintentional chemical or biological disasters, little is known about the psychological effects that are specific to chemical or biological terrorism. This lack of knowledge further emphasizes the need for updating protocols and providing additional training of health providers to assure adequate mental health support in existing disaster networks.
Agencies involved in these training effort are: (1) FEMA, providing grants to states, training emergency response, and coordinating delivery of federal counterterrorism; (2) the EPA, whose missions in terrorist attacks are to coordinate personnel and equipment; to respond to hazardous substances, to monitor and to assess the health and environmental impacts; to plan for control, restoration, and disposal of hazardous materials, and to train federal, state, and local response personnel and other

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responders dealing with hazardous materials emergencies; (3) the Department of Energy and the Nuclear Regulatory Commission, which are charged with providing nuclear and radiological training components to existing emergency response plans; (4) the Department of Health and Human Services, which is the lead federal agency for health and medical services during a presidentially declared disaster; and (5) the Office of Emergency Preparedness, which coordinates the federal health and medical response and recovery activities.
Large cities, such as New York, Chicago, Denver, Boston, and smaller municipalities in Kentucky, Rhode Island, and Massachusetts have developed training programs for their existing emergency response personnel. However, these programs, essential in the immediate remediation of the physical hazards of a terrorist attack, are not currently designed to integrate, plan, provide, or coordinate their efforts with specialty mental health response teams.
The American Psychological Association (APA) has a Disaster Response Network (DRN) of 1,500 psychologists, who have volunteered to provide on-site mental health services to disaster survivors and responders. The DRN services are integrated with the American Red Cross disaster response service and emphasizes brief crisis intervention, primarily for natural disasters. DRN has few psychologists with knowledge of chemical and biological agents that might be used in terrorist attacks. The DRN also does not include education on the neuropsychological impact and need for brief neuropsychological screening of victims of chemical, nerve gas, or biological weapons of mass destruction. DRN does not address either the issue of predictable mass mental health casualties following terrorist attacks or training in the necessary triage and collaboration with the many different state and federal agencies providing services in such an event.
The American Psychiatric Association has a similar but smaller group of volunteers in its Committee on the Psychiatric Dimensions of Disaster. The committee sponsors an introductory course on psychiatric aspects of disasters and a disaster workshop at the Annual Meeting and has developed written and audiovisual materials and distributed them to each of the Association's 77 district branches. In addition to this national level committee, many district branches have disaster committees which respond to local issues and needs. A summary of a 1996 conference on the role of psychiatrists in disasters, jointly sponsored with the American Red Cross and posted on the Internet at www.psych.org, suggested a number of initiatives aimed at educating psychiatrists about the Red Cross Disaster Mental Health Services and fostering a partnership between the two organizations.
In the United States, licensed psychologists, counselors, and psychiatrists

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are required to complete ongoing professional continuing education. Specific training programs awarding continuing education credits, and possible certification, for mental health crisis intervention after terrorist attacks could be developed and provided by the corresponding major professional organizations.
Community Effects In addition to meeting the psychological needs of individuals, emergency management officials must deal with the reactions of the community as a whole. An important part of any large-scale threat to public health is the psychological effects it engenders in the general public. This will be especially important in the case of chemical or biological terrorism, one goal of which is often to produce fear, panic, demoralization, and loss of confidence in government. Little is known about the fears and feelings engendered by the threat of infection, but considerable research on risk perception and risk communication has been conducted in connection with hazardous waste sites, nuclear power plants, and other real and perceived environmental threats, and general guidelines for government officials have been produced (Hance et al., 1988; National Research Council, 1989; Stern and Fineberg, 1996). Timely provision of accurate information about the nature of the threat and the action being taken to combat it is a central tenet of this advice. Training being provided to major cities through the Army's Domestic Preparedness Program could make that information available if it is implemented as planned (approximately 40 of the 120 cities scheduled had received training by November 1998). The committee has not been able to determine whether these or other cities have prepared information packages of their own for use in informing the press and the public in the event of a terrorism incident, but such preparation will surely be necessary if public officials are to maintain the confidence of a community deluged with information of widely varying accuracy in the news media and, increasingly, on the Internet.
R&D Needs The committee is concerned about several areas of the psychological response to chemical or biological terrorism. Among these areas of concern are the training of mental health professionals, methods for screening victims, and communication to the general public. Therefore, the committee has identified the following research and development needs.

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9-1
Identify resource material on chemical/biological agents, stress reduction after other traumas, and disaster response services, and enlist the help of mental health professional societies in developing a training program for mental health professionals. The key to success in this attempt will be offering continuing education credits and certification for mental health providers trained in chem/bio attack response.
9-2
Identify suitable psychological screening methods for use by mental health providers and possibly first responders, differentiating adjustment reactions after chem/bio attacks from more serious psychological illness (e.g., panic disorder, PTSD, psychosis, depression), and organic brain impairment from chemical or biological agents. Research to identify trauma characteristics and behavior patterns that predict long-term disability may be necessary.
9-3
Develop health education and crisis response materials for the general public, including specific communication on chemical or biological agents. Additional information is needed on risk assessment/threat perception by individuals and groups and on risk communication by public officials, especially the roles of both the mass media and the Internet in the transmission of anxiety (or confidence). Some information is available in EPA studies of pollutants and toxic waste, but there is little or no systematically collected data on fears and anxieties related to the possibility of purposefully introduced disease.
9-4
Evaluative research is needed on interventions for preventing or ameliorating adverse psychological effects in emergency workers, victims, and near-victims. Specific crisis intervention methods may be necessary for chemical or biological terrorist incidents, but in the absence of such incidents researchers might draw on studies of chemical spills, epidemics of infectious disease, and more conventional terrorist incidents.